This section provides readers with tools to clarify concepts and relationships in surrogacy arrangements, as well as ideas and strategies that could help change the way international commercial surrogacy is practiced.


Learn more about who is involved in a commercial surrogacy relationship with a simple info-graph connecting intended parents, gestational mothers, children, egg providers, and go-betweens.

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For more on each, and the connections in between, visit the Surrogacy Relationship and Resources.



This handout situates commercial surrogacy within the broader terrain of ARTs and related practices. It includes key technologies and practices that exist and are in the pipeline, differentiating between those that are mostly socially accepted and others that are more controversial. It challenges us to consider lines that should not be crossed as we strive for a safe, healthy, and just human future

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Surrogacy is more than the use of assisted reproductive technologies to have a child. It is also a social relationship.

Intended parents are aware there is a person, a gestational mother, on the other side of the contract. They understand their arrangement with this person is unique, regardless of the level of contact between them. They may not, however, be aware of their power, as paying clients, to improve conditions for gestational mothers within arrangements. Some might be hesitant to use this power, worried that doing so will delay or deny them a child. If all intended parents remember their influence, and use their voice for change, clinics and agents will eventually be held accountable to accepted standards of health care and safety.

Five areas on which intended parents can seek change are discussed below.
For more information on the issues covered under each, visit the Surrogacy Relationship and the Resources section for related articles and research.

Freedom of Movement and Unrestricted Access to Family

Staying physically active, socially engaged, and emotionally connected are hallmarks of a healthy pregnancy. Gestational mothers are often unable to leave the surrogacy residence at will and remain isolated from families (including their children) and communities through the pregnancy. The toll of these restrictions is impossible to quantify, but it is not hard for anyone to imagine. Intended parents can ask clinics to allow their gestational mother unrestricted – and preferably unsupervised – access to the outdoors and her loved ones.

Single Embryo Transfers Versus Multiples

An intended parent’s desire for a child — and a clinic’s motivation for success — means that gestational mothers often carry more than one embryo at a time. Multi-fetal pregnancies have implications on the health of women and children. To reduce risks related to multiple births and avoid the need for a selective reduction, intended parents can request one embryo transfer per pregnancy, as suggested by the U.S.-based National Perinatal Association and others, such as the World Health Organization.

Decisions On Remaining Or Not Remaining Pregnant

As in any other contractual arrangement, it is important to respect a gestational mother’s decisions related to her participation – if she wants to terminate a pregnancy (and withdraw from the contract) or see it through despite intended parents wanting otherwise. A conversation in advance can be helpful, so both sides understand the implications and expectations attached to decisions that are made or altered. This conversation must cover decision-making in the event of detected fetal anomalies.

Vaginal Births Versus Cesarean Sections

Cesarean sections can save lives when medically needed. However, they also present risks that are not associated with vaginal births. Gestational mothers routinely go through unnecessary and invasive abdominal surgery because it is a condition of their contract. This is for two reasons: first, to ease scheduling and maximize birth numbers at the clinic and second, to accommodate intended parents that wish to attend the birth of their child and need to plan travel.

Even if they know that cesarean delivery is a condition of their contract, a gestational mother may not know its effects on her recovery and long-term health. Those who want a safer option with documented benefits may be unable to negotiate a vaginal birth. And because many return to communities in which obstetrical care is limited or absent, gestational mothers can be at serious risk during subsequent VBACs (vaginal birth after a cesarean).

Intended parents can change these practices, by seeking an assurance from the clinic that their gestational mother understands the benefits of a vaginal delivery and contractually requiring one unless otherwise medically indicated. Given the difference in the cost of a vaginal birth versus a cesarean section, paying attention to the breakdown in fees for services – or requesting a breakdown – can help determine the clinic’s follow through.

Postpartum Follow-Up and Care

Postpartum support seems the exception rather than the norm for gestational mothers. Free medical care for at least three months after a birth (the “fourth trimester”) can help assess and manage risks. Psychological support services – to help recover from relinquishing a child, cope with lactation, re-assimilate with family, and resist any social stigmatization – is also important. Intended parents can include related clauses in the contract, pay for services in advance and, if possible, follow up with the clinic or the gestational mother.


We hope suggestions outlined in this tool will encourage intended parents to think about the implications of some current practices and work with gestational mothers and providers towards informed consent. One overarching step in this direction is the contract.

Contracts and Informed Consent 

Often, gestational mothers do not understand or are not conversant in the language in which the contract is written, generally English or the intended parent’s native language. In such cases, she signs the document and, by doing so, agrees to the contract conditions without actual informed consent. By insisting on bilingual contracts (in languages in which gestational mothers and intended parents are fluent) and the presence of an interpreter during all discussions, intended parents can take a major step towards informed consent and the changes suggested above. This will be covered in more detail in subsequent tools, along with navigating other aspects of the surrogacy arrangement for the benefit of intended parents, gestational mothers, and the children they birth. Please visit again soon.